REFERENSI KONSER1

8/10/2019 REFERENSI KONSER1

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1. Rotasi cairan irigasi dengan menggunakan berbagai jeniscairan adalah tidak efektif dan tidak mutlah untuk dilakukan

2. Cairan irigasi yang poten sampai sekarang dan masih bisa

diandalkan adalah NaOcl 5%, atau cairan bleaching ( un tukpemutih baju, bayclin ), karena sifatnya yang bsia menghilangkansmear layer dan mempunyai daya pembersih yang ampuh

3. drg marino menggunakan akuadest steril untuk pembilas,dan antiseptik klorhexidine, selain cairan utama memakai NaoCl

4. bila memakai pro taper atau jarum endo..diharuskan

memakai EDTA. Cairan EDTA berfungsi sebagai pelumassehingga tidak menyebabkan alat terlalu bekerja berat, bila tanpapelumas, bisa menyebabkan usia pakai yang singkat dari alat

tersebut ( aus ),

a.Mengurangi resiko jarum patah dengan bertindak sebagai pelumas/lubrikan

b. MEmbantu mendorong keluar debris

c. Permukaan saluran akar yang bebas smear layer dan dinding saluran lebih lunak

d. Pembersih kimiawi dengan menghilangkan smear layer (dengan pengguanaan peroksida)

e. Secara total menghilangkan debris karena sifatnya yang tidak menyerap air

rotaper Instrument ManualPOSTED BY DRG. ARDYAN GILANG RAHMADHAN SKG. ON 8:37 AM

Protaper instrument was made to provide flexibility and efficiency to achieveconsistently successful cleaning and shaping results. With Protaper instrument,root canal preparation are relatively easier and faster. Follow this guideline to useProtaper instrument.

Guidelines:

Establish straight line access Carefully flare the orifice(s) with gates glidden drills Use instruments in a well irrigated and lubricated canal Create a smooth glide path with small hand files Clean flutes frequently and inspect for signs of distortion
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Use SX to create more shape, as desired, in the coronal two-thirds Use instruments withrecommended motion.

Manual ProTaper Handle Motion:

Lightly engage dentin by gently rotating the handle clockwise until the file is just snug Disengage the file by rotating the handle counterclockwise 45-90 degrees Cut dentin by rotating the handle clockwise while simultaneously withdrawing the file Repeat handle motions until desired length is achieved Depending on the anatomy, Potaper files can be used as described above or by

reciprocating the handle in a back and forth motion.

The ProTaper Technique:

1. Fill the pulp chamber with either Protaper Glyde or Sodium Hypochlorite(NaOCl) for all initial negotiation procedures. Explore the coronal two-thirds of the canalwith stainless steel No. 10 and 15 hand files, using a reciprocating back and forth motion.Work these instruments passively and progressively until they are loose.

2. Start the Protaper sequence with S1 (purple). The apical extent of S1 willpassively follow the portion of the canal secured with hand files. S1 is designed to cut

dentin, in a crown down manner, with its bigger, stronger and more active blades.Irrigate, recapitulate with the 10K File to break up debris and then re-irrigate.

3. In more difficult canals, one, two or three recapitulations with S1 may benecessary to pre-enlarge the coronal two-thirds of the canal. Frequently clean the blades,then continue using this file until it reaches the depth of the 15 hand file. Irrigate,recapitulate and then re-irrigate.

4. Once the pre-enlargement procedure is finished, use a precurved No. 10KFile in the presence of NaOCl or Glyde to negotiate the rest of the canal and to establishpatency. Determine working length with No. 15K File.

5. When a smooth glide path to the terminus is verified, sequentially carry firstS1 then S2 to the full working length. Remember to irrigate, recapitulate and re-irrigateafter each Protaper instrument.
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6. With the canal flooded with irrigant, work the F1 to length in one or morepasses. If the F1 ceases to advance deeper into the canal, remove the file, clear its blades,

then continue with its use until it reaches length. Irrigate, recapitulate and re-irrigate.

7. Following the use of F1 to length, gauge the foramen with a 20 hand file. Ifthe 20 hand file is snug at length, the canal is shaped and ready to fill. If the 20 hand fileis loose at length, proceed to the F2 and, when necessary, the F3, gauging after eachFinisher with the 25 and 30 hand files, respectively.

Kemajuan teknologi semakin pesat dan telah berdampak langsung dalam ilmukedokteran gigi, khususnya pada bidang endodonti. Berbagai teknik daninstrumen

dalam perawatan saluran akar yang lebih efektif dan efisien telah banyak

berkembang. Salah satu instrumen preparasi saluran akar adalah denganmenggunakan instrumen rotatifProTaper. Instrumen rotatifProTaper merupakangenerasi barn dari instrumen rotatif NiTi yang didesain untuk mempertinggi

efisiensi pemotongan dentin dengan fleksibilitas terutama Pada bagian apikal dari

saluran akar yang melengkung. Jika dibandingkan dengan sistem NiTi lain makainstrumen rotatif ProTaper memiliki penampilan baru dengan taper yang

meningkat. Instrumen rotatif ProTaper memiliki desain convex triangular cross-sectional. Instrumen ini bekerja dengan menggunakan tenaga putaran 250-300 rpm

yang dihasilkan oleh motor. Instrumen rotatif ProTaper didesain untuk

menyediakan fleksibiltas superior, instrumentasi yang sulit, sempit, dan pada akaryang melengkung. Berdasarkan hal diatas maka dapat diambil pendapat bahwa

instrumen rotatif ProTaper memiliki adaptasi yang baik pacta saluran akar yang

melengkung dan sempit dimana dalam penggunaannya banyak kelebihan namunterdapat juga beberapa kekurangan yang hams diketahui oleh para klinisi karena

penggnnaan alat ini masih cenderung bam dikliuik. Prof. DR. Rasinta Tarigan,drg., Sp.KG
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Radix Entomolaris in Mandibular First Molars in Indian

Population: A Review and Case Reports

Kanika Attam,Ruchika Roongta Nawal,Shivani Utneja,andSangeeta Talwar

Conservative Dentistry & Endodontics, Maulana Azad Institute of Dental Sciences,New Delhi 110002, India

Received 14 August 2012; Accepted 20 September 2012

Academic Editors: D. Cogulu and C. Evans

Copyright 2012 Kanika Attam et al. This is an open access article distributed

under theCreative Commons Attribution License,which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work isproperly cited.

Abstract

Purpose. The aim of this paper is to present cases of mandibular first molars withan additional distolingual root and their management using appropriate instruments

and techniques.Basic Procedures and Main Findings. Mandibular molars can

sometimes present a variation called radix entomolaris, wherein the tooth has anextra root attached to its lingual aspect. This additional root may complicate the

endodontic management of the tooth if it is misdiagnosed or maltreated. This paperreviews the prevalence of such cases in Indian population and reports the

management of 6 such teeth.Principal Conclusions. (1) It is crucial to be familiar

with variations in tooth/canal anatomy and characteristic features since suchknowledge can aid location and negotiation of canals, as well as their subsequent

management. (2) Accurate diagnosis and careful application of clinical endodontic

skill can favorably alter the prognosis of mandibular molars with this rootmorphology.

1. Introduction

The primary aim of endodontic treatment is the elimination of bacteria from the

infected root canal and the prevention of subsequent reinfection. This is mainly

achieved by a thorough cleaning and shaping of the root canal, followed by a three-dimensional filling with a fluid tight seal. Establishing adequate access for

cleaning and shaping is an integral part of this procedure. In order to achieve these

endodontic goals, the clinician must have an in-depth knowledge of root canalanatomy and be aware of its anatomic diversities such as extra roots, extra canals,

webs, fins, and isthmuses that may complicate the endodontic procedure.
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Several authors have reported about the morphology of the mandibular first molars

[13]. These articles have shown that mandibular first molars usually have three or

four canals. Along with the number of root canals, the number of roots may alsovary. The majority of first and second mandibular molars are two rooted with two

mesial and one distal canals [3,4]. A major variant in this group is the mandibularfirst molar which has three roots. This has a frequency of less than 5% in whiteCaucasian (UK, Dutch, Finnish, German), African (Bantu Bushmen), Eurasian and

Indian populations. In those with Mongoloid traits, such as the Chinese, Eskimos,and native American populations, it occurs with a frequency of 5 to more than 30%

[58]. This third lingual root, first mentioned in the literature by Carabelli [9], is

called the radix entomolaris (RE).

For successful endodontic treatment of all canals of the tooth careful radiographic

diagnosis plays a pivotal role. Radiographs taken at different angulations reveal the

basic information regarding the anatomy of a tooth and can thus help to detect anyaberrant anatomy such as extra canals/roots [10]. However, a significant constraint

in conventional radiography is that it produces a two-dimensional image of a three-dimensional object, resulting in the superimposition of the overlying structure. To

achieve a more detailed understanding of the morphological structure of rootcanals and their interrelations, more advanced diagnostic tools are required.

Recently, cone-beam computed tomography (CBCT) has emerged as a useful tool

to aid in the diagnosis of teeth with complex root anatomies [11,12]. It is an

imaging method employing tomography to generate a three-dimensional

reconstruction of the entire tooth at different levels from a single imagingprocedure. The advantages of CBCT imaging are that it completely eliminates thesuperimposition of structural images outside the area of interest and provides a

high-contrast resolution and data from a single computed tomography imaging

process. Moreover, the images can be viewed in a coronal, sagittal, or even anoblique or curved image planesa process referred to as multiplanar Reformation

(MPR). In addition, CBCT data is amenable to reformation in a volume, rather

than a slice, providing three-dimensional images in the axial, coronal, or sagittalplanes [13].

RE has an occurrence of less than 5% in the Indian population, and such cases are

rarely observed during routine endodontic procedures. We report on six such casesin this paper. RE was observed in the mandibular first molars of three patients

being root canal treated. This anatomy was also present on three extracted

mandibular teeth which were studied in detail to gain an understanding of theirmorphological characteristics. Knowledge of such variations can be beneficial indelivering treatment to patients presenting with related diversities in their root

canal anatomy.

2. Case Reports
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Case 1. A 22-year-old Indian female patient reported complaining of pain in a

lower-right posterior tooth for a few days. The lower right first molar tooth had

been restored with an amalgam restoration 10 years prior to this. Examination ofthe tooth revealed a large occlusal amalgam restoration with marginal ditching and

tenderness to percussion. The mobility of the tooth was within physiologic limitsand vitality testing revealed the tooth to be nonvital. The medical history of thepatient was noncontributory. Radiographic examination (Figure1(a))revealed the

restoration close to the distal pulp horn and periapical lamina dura widening. Italso revealed the presence of an additional supernumerary root on distolingual

side. In addition, a computed tomographic scan (Figures1(b),1(c),and1(d))of the

lower jaw of the patient was available for surgical reasons. On evaluation, the scanillustrated the nature of origin and curvature of the extra root in a mesiobuccaldirection as depicted by the arc (Figure1(d)). The extra root originated from the

distolingual part of the tooth and curved mesially.

Figure 1: (a) Diagnostic radiograph, (bd) computed tomographic scan in coronal,middle, and apical segments, respectively, (e) access cavity preparation, (f)working length determination, (g) post obturation, and (h) full coverage

restoration.

A diagnosis was made as chronic apical periodontitis due to pulpal necrosis of thelower right first molar tooth. The pulp chamber was accessed and two mesial canal

orifices and one distal canal orifice were located. In addition a dark line guided the

operator towards an extra orifice located towards the distolingual part of the pulpalfloor (Figure1(e)). The root canal orifices were enlarged using gates glidden drills(Mani Inc., Kiyohara industrial park, Utsunomiya, Japan) to obtain a straight line

access which modified the access shape to a more trapezoidal form. The rootcanals were explored with precurved K-file ISO number 15 (Dentsply Maillefer,

Ballaigues, Switzerland), and radiographic length measurement was performed

(Figure1(f)). The root canals were instrumented using the ProTaper rotary files(Dentsply Maillefer, Ballaigues, Switzerland) in all the canals. During

instrumentation adequate irrigation was performed using 1% sodium hypochlorite(I-Dent, Rohini, Delhi, India) and lubricated using Glyde (Dentsply Maillefer,

Ballaigues, Switzerland). Obturation of the root canals was performed using AH

plus sealer (Dentsply, Maillefer, Ballaigues, Switzerland) and correspondingProTaper gutta percha points (Figure1(g)). Postendodontic coronal restoration wasdone with full metal crown (Figure1(h)).

Case 2. A 22-year-old Indian male patient reported to the Out Patient Department

complaining of an inability to chew with lower left posterior tooth for the
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preceding few days. On clinical examination, the lower left first molar tooth had

distoproximal caries and was tender to percussion. The periodontal status of the

tooth was clinically normal, and the tooth had physiologic mobility.

Radiographic examination (Figure2(a))revealed periapical lesion in relation toboth the mesial and distal roots of the tooth. It also revealed the presence of asupernumerary root in addition to a mesial and a distal root. The extra root

originated from the distolingual part of the tooth and appeared to be relatively

straight. As the tooth was unresponsive to electric pulp testing, it was diagnosed

with pulpal necrosis and chronic apical periodontitis.

Figure 2: (a) Diagnostic radiograph, (b) access cavity preparation, (c) workinglength determination, (d) master cone confirmation, (e) postobturation, and (f)

eight-month followup.

The pulp chamber was accessed, and two mesial canal orifices and one distal canalorifice were initially located. On further exploration, another orifice was locatedtowards the distolingual part of the pulpal floor (Figure2(b)). The root canals were

explored with a K-file ISO number 15 and radiographic length measured

(Figure2(c)). Instrumentation was carried out using the ProTaper rotary files with

intermittent irrigation using 1% sodium hypochlorite in all the canals. Master coneradiograph was obtained (Figure2(d)). Obturation of the root canals was

performed using the ProTaper gutta percha points and AH Plus sealer

(Figure2(e)). An eight-month follow-up radiograph of the patient illustratedresolving periapical radiolucency (Figure2(f)).

Case 3. A 24-year-old female patient presented with pain in her lower rightposterior region. The pain was continuous in nature and aggravated with hot food.

On intraoral examination, an old leaking composite restoration was seen in thelower right first molar tooth. The tooth was hypersensitive to both hot and cold

stimuli and was tender to percussion although no pathologic mobility was

observed. Radiographic assessment of the tooth revealed a large occlusalrestoration close to the pulp of the tooth with an extra distal root. To confirm this

observation, another radiograph at a horizontal angulation of 20 degrees was taken

which clearly revealed the presence of an extra distal root that curved severelytowards the mesial root (Figure3(a)). No periapical changes could be seen thus a

diagnosis of irreversible pulpitis was made, and root canal treatment was decided

as the treatment option.
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Figure 3: (a) Diagnostic radiograph, (b) access cavity preparation, (c) workinglength determination, and (d) postfilling.

Upon access to the pulp chamber, the distal orifice was seen located eccentrically

towards the buccal aspect of the tooth (Figure3(b)). Following the laws of orifice

location [14], another orifice was located on the distolingual side. The coronalshaping of all of the orifices was done using Gates Glidden drills (number 13). A

number 10K file was loose in all canals except in the disto-lingual canal where it

stopped 3mm short of the radiographic apex. Since there was a sharp apicalcurvature (Figure3(c))in the disto-lingual root, C+ files (Dentsply, Maillefer,

Ballaigues, Switzerland) with batt tips (a unique feature of C+ files) were used tonegotiate the canal. The canals were shaped from coronal to middle and apical to aProTaper size F2 (Dentsply, Maillefer, Ballaigues, Switzerland) and obturated

(Figure3(d))using the corresponding gutta percha cones.

3. Extracted Teeth

Three extracted teeth which exhibited RE morphology were also clinically and

radiographically assessed. In all of the teeth, the extra root emerged from thelingual aspect of the tooth (Figures4(a),4(e),4(i),4(b),4(f),and4(j))either

attached to the distal root or midway between the mesial and the distal roots. Afterseparating from the tooth, the root usually ran straight for the coronal part of itslength and then in the middle or apical third, and it curved buccally and/ormesially. The third root was narrow and tapering towards the apex with a variable

length. Thus care should be taken not to overprepare and shape such root canals to

avoid any inadvertent perforation of the root (Figures4(d),4(h),and4(l)).

Figure 4: (a, e, and i) Lateral view of the extracted teeth, (b, f, and j) mesial view

of the extracted teeth, (c, g, and k) access cavity preparation, and (d, h, and l)

radiographic appearance.

Access opening was performed on all of the extracted molars (Figures4(c),4(g),and4(k)). The location of the supplemental orifice was in a distal and/or lingual

position, at times nearing the external enamel wall. To establish straight line

access, it was required to have sufficient coronal enlargement using gates gliddendrills.
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4. Discussion

Anatomical variations are an acknowledged characteristic of mandibular

permanent molars. Although a majority of the mandibular molars are two rootedwith a mesial and distal root, an extra disto-lingual root may occasionally be

encountered. Some authors consider a radix entomolaris as a genetic trait ratherthan a developmental anomaly [6,15]. They have suggested that these three-

rooted molar traits had a high degree of genetic penetration as reflected in the fact

that pure Eskimo and Eskimo/Caucasian mixed-race individuals had a similarprevalence of the trait. While it may be a normal morphological variant in ethnic

groups of mongoloid origin (>30%), it has rather low prevalence (


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different horizontal projections, the standard buccal-to-lingual projection, 20

degrees from the mesial and 20 degrees from the distal reveals all the basic

information regarding the anatomy of the tooth [21,22]. Cone-beam computedtomography has emerged as a useful tool to aid in diagnosis of complex root canal

anatomy. In the first case report the CBCT images revealed the location anddirection of the curvature. This was extremely beneficial during cleaning, shaping,and obturation of the type 3 curvature seen in this root.

Once a diagnosis is reached and an access cavity has to be prepared, care should be

taken to establish a straight-line access. With thedisto-lingually located orificeof the RE a modification of the classical triangular access cavity to a trapezoidalform is required to locate and access the root canal. The laws of orifice location

[14]may aid in the location of extra orifices. However, care must be taken to avoid

gouging or excessive removal of dentin as this may weaken the tooth structure.

Based on the literature, the majority of radices entomolaris are curved. In somecases there is an additional curve starting from the middle of the root or in the

apical third. Hence using precurved files, to establish a smooth glide path to theapical segment and Nickel-Titanium rotary files for cleaning and shaping, is the

desired option [23]. Adequate coronal enlargement avoids hindrances in thecoronal segment of the canals and easy passage of the endodontic file to the apicalsegment. It would also allow root canal irrigants to pass on to the apical segment in

larger volumes. Radiographs taken at different angulations/CBCT scan of the tooth

should be studied carefully to estimate the root length and curvature. The root

length in such cases can be confirmed with the help of electronic apex locators.Nonetheless, in spite of using the state-of-art gadgets endodontic mishaps mayoccur, and thus care has to be taken while negotiating and cleaning these curved

canals.

5. Conclusion

Radix entomolaris has been reported to occur with a frequency of 0.232% indifferent populations. It is crucial to ascertain the exact nature/characteristic of the

RE in terms of curvature and conformation to carry out a proper treatment.Therefore, such cases require judicial application of diagnostic tools and

endodontic skills for their management. Careful interpretation of the radiograph,using different horizontal cone projections and advanced tools such as CBCT, may

facilitate their recognition. Once diagnosed, management of the extra canal and

root can be done using equipments such as magnification aids, orifice locators andflexible files.
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